Neale R. Chumbler, Western Michigan University and James W

Free Inquiry In Creative Sociology
Volume 24 No. 1, May 1996
Page 59
SURGICAL SPECIALIZATION IN A LIMITED HEALTH CARE PROFESSION:
COUNTERVAILING FORCES SHAPING HEALTH CARE DELIVERY
Neale R. Chumbler, Western Michigan University and
James W. Grimm, Western Kentucky University
ABSTRACT
This study investigated correlates of surgical specialization among a group of no~hysician specialistspodiatrists. Placed in the context of a countervailing powers perspective, we investigate one research question
not previously examined among a group of limited-health professionals: Is the current wor1< environment of
podiatrists (e.g. , practice locations, wor1< in a hospital, physician referrals), as compared to their prior education
and sociodemographic characteristics, more likely to be associated with surgical specialization? Results show
that respondents who practiced in more than one office location, who made referrals to endocrinologists, and who
had full medical-staff privileges in a hospital had the greatest likelihood of claiming specialization in surgery.
Implications of the findings are discussed in terms of how developments in podiatry are related to a reconfiguration
of health care delivery by involving podiatrists increasingly with the traditional wor1< and authority of physicians.
INTRODUCTION
Recent sociology of medicine research
has reported on the importance of a new
theoretical perspective, that of countervailing
powers, in order to better understand professional dynamics that include the interrelationships among established medicine and
limited-medical professions (e.g., podiatric
medicine) (Abbott 1988; Hafferty, Light 1995;
Halpern 1992). The countervailing powers
perspective suggests that established medicine is shaped by
maintenance organizations (HMOs) and preferred provider organizations (PPOs), that provide cost-conscious motivations for how and
why care is to be delivered (Wirth, Allcorn
1993). In the past, the health care industry
operated on a fee-for-service model where
patients solicited care on their own, using
physicians they wanted . Once selected, the
physician was completely autonomous in providing whatever care patients desired (Ferraro
1993; Wirth , Allcorn 1993). Now, HMOs extend
the particular configuration of countervailing
institutional powers, and all within a framewor1<
of professional dynamics that includes professional ascension as well as professional maintenance and professional decline. (Hafferty,
Light 1995)
contractual responsibility for care to a voluntarily
enrolled, defined population in exchange for a
fixed annual ormonthlyfee independent of use
of services. (Ferraro 1993)
Consideration ofthe countervailing powers perspective has been a redirection of both
professional work in cross-profession arenas
and jurisdictional control that determines how
such cross-profession domains may be changing and delimiting the traditional authority of
established medicine (Hafferty, Light 1995;
Halpern 1992). From a variety of institutions
and groups, countervailing pressures have
eroded physicians' hegemony. These countervailing pressures include, but are not limited
to, demographic changes and significant
changes in reimbursements for services, managed care arrangements, and the increased
role of other health care occupations in treatment networks with physicians (Chumbler,
Grimm 1994, 1995; Hafferty, Light 1995).
The term "managed care" is used generically to describe all types of integrated
health care delivery systems, such as health
Under various HMO plans, primary care physicians (physicians who specialize in either
family practice, general internal medicine, or
general pediatrics) have more power relative
to physician specialists, by controlling and
monitoring patient referrals to specialists
(Wirth, Allcorn 1993; Xu, Veloski, Hojat, Fields
1995). Therefore, in the context of contemporary management of patient referrals, primary
care physicians are often called "gatekeepers.•
HMOs perform the dual function of being both the insurer and the provider of health
care (Ferraro 1993; Wirth, Allcorn 1993). OVer
15 percent of the U.S. population (36,482,090)
were enrolled in HMOs by July 1991 (Ferraro
1993; Macleod 1993). This fundamental
change-from the traditional fee-for-service
care model to the pre-paid group mode~as
given expanded roles to some health care
occupations and also diminished the degree to
which physicians dominate the jurisdictional
control of health care (Ferraro 1993; Hafferty,
Page 60
Volume 24 No. 1, May 1996
Light 1995).
Previous studies have presented historical evidence suggesting that physicians
have lost some of their autonomous control
over their anatomical areas of expertise (Abbott
1988; Halpern 1992). Results of such studies
suggest that more power is lost when common
worit takes place in large, multi-field organizations such as hospitals (Abbott 1988; Wirth,
Allcorn 1993). Conversely, less power is lost to
limited medical professions if they have the
exdusive control of worit and if medicine has
the exdusive source of supervisory control
over challenging groups (Halpern 1992). Therefore, past research has focused on aspects of
medicine in relation to woritsites as key issues
in detennining the amount of jurisdictional
authority lost to or shared with groups seeking
increased jurisdictional control over worit
shared with physicians (Hafferty, Light 1995).
However, what continues to be missing
from the literature is infonnation on the
changing nature of medical wor1t as it is
re-
configured across the various health occupations.... Like medicine, other health occupations are becoming highly stratified. (Hafrerty,
light1995)
To fill an important void in the literature on
stratification among health occupations, the
present study shifts the focus from jurisdictional resolution of cross-profession worit in
health care settings (Hafferty, Light 1995) to
an examination of a group of podiatrists, foot
specialists who are not physicians, but have
characteristics of practice similar to them (Skipper, Hughes 1983).
Countervailing Forces within Podiatry ..
Podiatrists are trained at colleges of
podiatric medicine and from a curriculum that
is very similar to those of medical schools
(Helfand 1987). Podiatrists typically treat types
of "foot problems for which physicians, in
general, have not been particularly indined to
show special interesr (Skipper, Hughes 1983).
For instance, podiatrists are likely to treat
minor foot ailments (such as corns, calluses,
and bunions) (Wylie-Rosett, Walker, Shamoon,
Engel, Basch, Zybert 1995). Nevertheless,
podiatrists have not obtained full autonomy
over the foot. For instance, physicians rather
than podiatrists have the authority to amputate
the foot (Skipper, Hughes 1983). However, like
primary care physicians, podiatrists perfonn a
Free Inquiry In Creative Sociology
vital role in the health care delivery system
because many ailments ofthe feet are considered a significant health problem patients
regular1y seek initial treatment from podiatrists (Skipper, Hughes 1983; Wylie-Rosett et
al1995).
Podiatrists also can perfonn a gatekeeper role by detecting severe conditions,
especially with diabetics, and by making referrals to physicians (Chumbler, Grimm 1995).
The Centers for Disease Control and Prevention recommended that the feet of diabetic
patients should be examined at every visit to a
provider (Wylie-Rosett et al1995). When treating the foot-related ailments of diabetics, especially those who are over age 65, podiatrists
are common sources of referrals to endocrinologists, medical sub-specialists who diagnose and treat individuals with diabetes. In
1992, fourteen million Americans had diabetes, and 55,000 ofthem had lower-limb amputations. Research suggests that 50 percent of
these amputations would have been preventable based upon early detection by means of
examinations and treatments provided by podiatrists (Wylie-Rosett et al 1995).
In the context of managed health care
provision, the present study does not imply
that podiatrists have obtained full autonomy
over their anatomical area of expertise, or that
they have more authority to treat foot ailments
than physicians. However, in this era of costconscious and managed provision of care, we
are studying podiatry as an excellent example
of a field which is becoming an alternative
source of treatment that could be, but is not
provided by physicians (Chumbler, Grimm
1995; Hafferty, Light 1995). More specifically,
the present study is primarily focused on exploring the characteristics of podiatrists who
daim specialization in surgery. Podiatric surgical activity, especially as it takes place more
in hospitals, is considered to be a key
countervailing force which has impacted and
will continue to impact the traditional hegemony of physicians (Levrio 1987, 1992).
In the analysis presented below we shift
the major sourceS-Of evidence of countervailing
forces that reduCe the hegemony of physicians
from historical records of professional associations (Abbott 1988) and litigation records or
other legal data (Halpern 1992) to self-reported characteristics of practitioners' educationaU
professional training, their sociodemographic
backgrounds and their practice environments.
Such data are a rich, yet under-utilized, source
Free Inquiry In Creative Sociology
of information on the rapidly increased role of
providers other than physicians (Hafferty, Light
1995).
Surgical Specialization within Podiatry
The emergence of a fonnally recognized
surgical specialization within podiatric medicine has been a slow, arduous process, resulting in multi-option training (Chumbler, Grimm
1995; Levrio 1992). The podiatrists who specialize in surgery either have hospital residency training and certification in podiatric
medical surgery (Grimm, Chumbler 1995), or
they have perfonned a preceptorship under
the direction of a certified podiatric surgeon
(Levrio 1987, 1992). Another difference between podiatrists who specialize in surgery
and physicians who specialize in surgery,
centers around practice structure. Being surgically specialized in podiatric medicine does
not mean full-time specialization; it is not
uncommon for podiatrists to actively participate in surgeries and also provide primary
podiatric care for a variety of common foot
ailments. Given that surgical specialization
among podiatrists is difficult to establish
through objective criteria related to preparation for actual practice activity, in this study we
use a self-reported item representing podiatrists affinning the predominant role of surgery
in their practices.
Trends within podiatry that also may be
related to podiatrists' propensity to specialize
in surgery are the advancement of educational
and professional training within podiatry and
podiatrists' expanded surgical activity gained
through staff privileges in hospitals (Grimm,
Chumbler 1995). By the 1980s, approximately
75 percent of podiatrists practicing in the
Chicago Metropolitan Statistical Area-the location ofthe study sample--had gained some
type of hospital medical staff privileges. Previous studies found certain sociodemographic
traits of podiatrists such as their age and
gender to be related to surgical specialization
in podiatry. For instance, as compared to male
podiatrists, females were less likely to report
surgical activity in their private practices
(Chumbler, Grimm 1993). Other research has
found that relatively younger podiatrists (those
40 years of age or younger) were more likely
to have completed surgical residency training
and less likely to refer surgical cases to other
podiatrists (Grimm, Chumbler 1995). Past
research also demonstrated that in comparison to Caucasian podiatrists, African
Volume 24 No. 1, May 1996
Page 61
Americans were less likely to have completed
surgical residencies (Chumbler, Grimm 1994).
Certain aspects of podiatric medical practice also may be key components ofthe countervailing forces within podiatry that are confronting the traditional scope of physicians' traditional practice activity and power. Abbott (1988)
argued that when different health care occupations perfonn similar work in common work
settings (e. g., hospitals and large clinics) crossfield accommodations called "systems of professions" develop. Thus, structural aspects of
podiatric medical practice that could be important elements of countervailing forces of surgical practice activity include: 1) number of
office locations, including clinics, hospitals &
group practices; 2) hospital staff privileges;
and 3) the amount of hospital practice activity.
The present study also examines the
referrals made by podiatrists to three types of
physician specialists, pediatricians, orthopedists, and endocrinologists. These three
specialists represent common destinations of
patient referrals from podiatrists in specific
configurations of treatment sequences. Foot
problems related to infants and children are
common. So common, that a sub-specialty,
pedo-podiatry, has emerged to treat some foot
ailments of infants, children and adolescents.
However, pediatricians still treat most foot
problems of children and therefore receive
frequent referrals from podiatrists (Helfand
1987). Orthopedists receive many referrals
from podiatrists, since they perfonn many foot
surgeries, especially those dealing with severe
bone fractures of the foot and ankle (Weiner,
Steinwachs, Frank, Schwartz 1987). Likewise,
endocrinologists receive many referrals from
podiatrists because podiatrists are the first
and often continue to be the most frequently
seen provider of treatments for foot ailments
related to diabetes.(Helfand 1987).
To better understand the role of podiatry
in the expanded and more oomplicated hierarchy of power and professional activity of health
care providers suggested by the countervailing
forces perspective, we provide the needed
infonnation recently called for by Hafferty and
Light (1995). They call for the need for determining whether aspects of work settings or
prior socialization (training and certification)
are more important in detennining the realignments of professional activity and professional allegiances. Additionally, previous research on physicians emphasized the influence of work settings rather than medical
Page 62
Volume 24 No. 1, May 1996
training to explain professional activity and
orientations (Abbott 1988; Freidson 1970a,
1970b; Wolinsky 1988). However, little remains known about the relative importance of
these factors in alternative providers, particularly podiatrists.
Based on the literature discussed above,
we investigate the following research question:
1) Does the currentwoi'X environment of podiatrists (e.g., practice locations, woi'X in a hospital,
patient referrals to physicians) or the prior education/professional training and sociodemographic characteristics ofpodiatrists more likely
to be correlated with surgical specialization?
METHOD
Sample
Questionnaires were mailed to a fifty
percent sample (N=280) of all podiatrists practicing in the Chicago Metropolitan Statistical
Area (MSA), during March 1991 . One hundred
sixty-eight completed questionnaires were returned, yielding a response rate of 60.0 percent. The sampling frame contained a list of
the names, addresses, and phone numbers of
all podiatrists practicing in the Chicago MSA.
The names of podiatrists that had the Chicago
school of podiatric medicine as their primary
practice location were deleted from the sampling frame. This was done to derive a sample
of respondents practicing primarily in the nonacademic community. The Illinois Podiatric
Medical Association (IPMA) provided the authors w 'th the sampling frame, only 10 days
old at the time of receipt.
The study sample was compared to two
other samples, a regional sample of Chicago
MSA podiatrists conducted by the Illinois
Podiatric Medical Association (IPMA 1987)
and a national sample (Skipper, Pippert 1985),
to determine its representativeness. Five distributions were compared across all three
samples, using the Chi-square goodness-offit test (p<.05): 1) gender; 2) age; 3) proportion
in group practices; 4) proportion on hospital
medical staffs; and 5) the duration of residency
training. The study sample had a larger proportion offemale respondents. Otherwise, the
differences between the study sample, the
IPMA regional sample, and the national sample
were not statistically significant (Chumbler,
Grimm 1993).
Free Inquiry In Creative Sociology
Measurement
Surgical Specialization
We assessed podiatrists' surgical specialization with a binary variable that contrasts
respondents who describe their practice as
surgically specialized (scored 1) with those
who do not describe it (scored 0). Approximately 58 percent of the respondents described their practice as being surgically specialized.
Sociodemographic and EducationaV
Professional Training
We employed three sociodemographic
variables: age (years); race (1=white); and
gender (1=male). We used three educational/
professional training indicators that reflect the
training and credentials of respondents: residency training (1=yes); length of residency
training for those with it (years); and national
certification in surgery (1 =yes). A majority of
the study sample were male (83%), white
(90%), and neither residency trained (51%),
nor nationally certified in surgery (70%). Ages
of respondents ranged from 25 to 78, with a
mean of 42.2 years (median=39.00) and a
standard deviation (SD) of 11 .79 years. The
length of residency training ranged from one to
four years, with a mean of 1.5 years (median
=1.00, SD=.81 years).
Professional Practice Characteristics
The professional practice settings of
podiatrists were measured by four dichotomous variables: solo practice (1 =yes); number of office locations (1 =two or more); length
at current office location (1= 11 or more years);
and location of practice within the Chicago
MSA (1=suburbs and outlying communities or
outside of city). Approximately three-fourths
(74%) of respondents were in solo practices,
slightly over one-half (52%) indicated two or
more office locations, over one-third (37%)
had practiced 11 or more years at the current
location(s), and 64 percent practiced either in
the suburbs andlor outlying communities.
Referrals to Physicians and Hospital
Orientation
Respondents were queried about
whether they made at least one patient referral
within the past four weeks to the following
physician specialists: pediatricians (1 =yes),
orthopedic surgeons (1 =yes), and endocrinologists (1 =yes). One-third of the respondents
reported practicing referrals to pediatricians,
Free Inquiry In Creative Sociology
Volume 24 No. 1, May 1996
Page 63
Table I: Logistic Regression Results of
Characteristics on the Likelihood of
Podiatrists' Surgical Specialization
Logistic
Coefficient/ Odds
Independent Variables
Standard Ratio
Error
Sociodemographic
-.021.03
.98
Age
.40/.64
1.50
White
.5<4/.<49
1.72
Male
Educational/Professional Training
1.54
.<43/.63
Residency
1.37
.321.29
Length of Residency
.79/.<48
2.20
Surgical Certification
Professional Practice
-.03/.<45
.97
Solo Practice
1.17/.39**
3.21
Number of Office Locations
Length at Current Location
. 19/.19
1.20
-.03/.<43
.98
Practice Outside City
Referrals to Physicians
.15/.<43
.98
Pediatricians
-.25/.<49
.78
Orthopedic Surgeons
1.30/.<45**
Endocrinologists
3.66
Hospital Orientation
-.011.03
.99
Number of Hrs/Wk
Practiced in Hospitals
Full Medical Staff Privileges
1.021.<47*
2.76
in a Hospital
-2.57
Intercept
167
N
Model x-squaredldf
<48.68115
Dep. var. mean
.58
Pseudo R-squared
.226
*p<.05; **p<.OI
regression. in logistic regression the dependent
variable is the natural log of the odds of a given
response category (Hosmer, Lemeshow 1989).
The log odds can be transformed into odds
ratios, or exponentiated regression coefficients,
allowing for an easier form of interpretation.
The odds ratio (OR) represents the relative
change in the odds of specializing in surgery
given one-unit increase in the independent
variable, adjusting for all other variables. To
show how well the model fits the data, we
refort the model chi-square and the pseudo
R , a descriptive measure that is a rough estimate of the variation in surgical specialization
accounted for by the independent variables
(Knoke, Borhnstedt 1994). The independent
variables were force selected into the logistic
regression model. We used the listwise deletion procedure for missing data. Remarkably,
only one case was deleted due to missing data .
Therefore, the final sample size for the multivariate analysis was 167.
We performed several diagnostic tests
in order to assess whether or not our results
satisfied regression assumptions. For instance,
we screened for multivariate outliers and found
no meaningful violations that affected the descriptive statistics. Second, we found that the
residuals met the assumptions of linearity,
normality, and homoscedasticity. Third, we
found weak collinearity, yielding confidence in
the precision of the beta coefficients. Specifically, investigation of variance inflation factors
(VIFs) for all the independent variables were
less than 1.7, while most were around 1.0.
VIFs greater than 10 are considered an indication of bias (Neter, Wasserman, Kutner 1990).
three-fourths made referrals to endocrinologists, and 79 percent reported referrals to
orthopedic surgeons. Hospital practice activities of podiatrists were assessed by the number of hours practiced in hospitals (hours/
week), and whether the respondent possessed
full medical-staff privileges in a hospital (1 =yes).
Nearly two-thirds (64%) of respondents spent
no hours per week in the hospital. Ofthose who
did, the average number of hours per week
was five (median = 3.00, SO= 7.54 hours). A
majority (71%) of respondents reported full
medical-staff privileges in hospitals.
RESULTS
Table 1 presents the logistic regression
model, with podiatric surgical specialization
as the dependent variable. Results in Table 1
include the unstandardized logistic regression
coefficients, followed by standard errors, odds
ratios, and significant p-values indicated by
means of asterisks.
Results indicate that, net of the estimated effects of the sociodemographic, educational/professional training, professional
practice, referrals to physicians, and hospital
orientation characteristics, the following three
variables (with their respective odds ratio in
parentheses) had significant associations with
self-reported surgical specialization among
the podiatrists we studied:
Multivariate Analysis
Since the dependent variable-surgical
specialization-is dichotomous, the appropriate multivariate analytic technique is logistic
Page 64
Volume 24 No. 1, May 1996
1) practicing in two or more office locations
(odds ratio= 3.21 , p<.01 );
2) making at least one patient referral to an
endoainologistfourweekspriortothestudy
(odds ratio= 3.66, p<.01 ); and
3) holding full medical-staff privileges in a hospital (odds ratio= 2.76, p<.05).
A fourth variable, national certification in
surgery, approached statistical significance at
p<.05. More specifically, respondents were
surgically certified were two times more likely
(p=.08) to be surgically specialized, as compared to those without such certification. Collectively, all 15 independent variables accounted for a significant, albeit a modest,
proportion of variance explained in surgical
specialization (pseudo R2 = .226).
DISCUSSION
Surgery has played a key role in enhancing the roles of podiatrists in health care
as well as expanding their training for contemporary practice activity (Grimm, Chumbler
1995; Levrio 1987, 1992). Understanding what
aspects of podiatrists' training for and involvement in surgical specialization helps explain
the important changes in podiatry which have
impacted the traditional authority and practice
activities of physicians (Hafferty, Light 1995).
Results of our multivariate analysis show
that neither the sododemographic background
(age, gender, and race) or professional training (completion of a residency) were assodated with respondents' surgical specialization.
Presont results fail to suppOrt previous research that indicated men were more likely
than women to dedare surgical specialization
in podiatry.
The finding that surgical certification
was correlated with surgical specialization
runs contrary to notion that practice environments are more important than sociodemographic and educationaVprofessional training
characteristics. We should point out that this
finding approached statistical significance and
was not significant at the customary level of
p<.05. In the years to come, surgical certification may emerge as a stronger correlate of
surgical specialization because other research
has shown that surgical specialization yields
more patient referrals from other podiatrists
(Grimm, Chumbler 1995). Certification in
surgery may underlie patterns of patient referrals among podiatrists which result in the
existence of a surgically-based specialty in
Free inquiry Jn Creative Sociology
podiatry. Therefore, credentials appear to play
a key role in the process by which specialties
are recognized in fields other than those involving physicians.
The study results identified that the number of office locations rather than their structures (i.e., solo versus group practices) or geographical locations (i.e., within or outside the
city of Chicago) as strong associations with
surgical specialization. One possible interpretation of this outcome is that patient referral
exchanges between podiatrists and physicians
are significantly more likely if podiatrists' offices were located in hospitals andlor multigroup office complexes where physicians are
located. Rather than geographical location
and structural nature of podiatric medical practice, it may be that locations allowing reciprocal patient referrals are more likely to enhance
the likelihood that podiatrists dedare surgical
specialization and engage in more surgeries.
The strong and positive relationship
between referrals made to endocrinologists
and surgical specialization is analogous to the
findings and outcomes of patient exchanges
between physicians and podiatrists (Chumbler,
Grimm 1994, 1995). In a recent study of older
diabetic patients in four New York (inner-city)
family care clinics , Wylie-Rosett et al (1995)
found that 35 percent of all patient charts
provided evidence of foot care referrals from
primary care physicians, mostly to podiatrists.
Thus, what may be involved in the reconfiguration of treatment for older adults with
diabetes is dual roles played by podiatrists.
With 14 million Americans having diagnosed
diabetes, it is imperative for managed care
organizations to effectively and efficiently assess each patient with diabetes and acknowledge that podiatrists are one of several practitioners that should treat diabetics. Physicians who practice in medical groups should
have surgical podiatrists as colleagues who
they can discuss cases (Wirth, Allcorn 1993).
The results showed that full medicalstaff privileges in a hospital rather than amount
of hours per week working in a hospital was
significantly associated with surgical specialization. Even though podiatrists still perform
some surgeries in their offices rather than
hospitals, our results suggest that it is the
membership on hospital medical staffs which
allows podiatrists to enhance their surgical
prowess. Previous research on health care
occupations has suggested that linkages
with hospitals permits the professional
Free Inquiry In Creative Sociology
environment for role expansion (Abbott 1988;
Hafferty, Light 1995). Results from the present
investigation corroborate previous research
suggesting that podiatrists with full-medical
staff privileges in a hospital are likely to be
involved in surgical activities and exchange
patient referrals with physicians (Chumbler,
Grimm 1995; Grimm, Chumbler 1995). Thus,
our research showed that work settings are not
necessarily the only or even the predominant
force behind integrated relationships between
physicians and other providers.
Interpretations of our findings are limited because of the data. First, our response
rate was decent, but not to optimal. Even with
the modest response rate, the sample was
representative of the most recent samples of
Chicago area and nationwide podiatrists. Another weakness of the study is that we were
unable to collect any data on the respondents'
perceptions of managed care organizations or
their future role in such organizations.
CONCLUSION
Overall, our exploratory study provided
some indications of why podiatry played an
increased role in health care as compared to
the traditional authority and practice activities
of physicians. We found that neither the absence nor full autonomy nor full time surgical
specialization prevented podiatrists from sharing more work with physicians. In fact, it is
because many podiatrists are both specialists
and primary-care providers that they have
several viable ways to share work with physicians. Interestingly, we found that both work
settings and credentials are a part of the
process by which podiatrists' work helps
reconfigure the activities of other providers.
Future research could use these findings as an impetus for examining the changing
nature of medical work in other health care
occupations, for example, clinical nurse specialists, nurse practitioners, and physician
assistants. As Hafferty and Light (1995) pointed
out, more information needs to be known
about the internal activities of these occupational groups, and to be understood about how
they are positioning themselves relative to
other practitioners in U.S. health care delivery
system .
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Free Inquiry In Creative Sociology
ACKNOWLEDGEMENT
The authors wish to thank the Research Committee of
the Illinois Podiatric Medical Association (IPMA) and
Mr.John F. Settich, Director of the IPMA, for valuable
assistance.